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| Catalog Number |
662346 |
| Medical Device Problem Code |
Migration (4003)
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| Health Effect - Clinical Code |
Insufficient Information (4580)
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| Date of Event |
09/08/2025
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Type of Reportable Event
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Serious Injury
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Event or Problem Description
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As reported: "a pangea distal femur plate was placed on (b)(6) 2025 there was a revision case done on (b)(6) 2025 where it showed multiple 5.0 locking screws going through the plate hole.Lateral x-ray from the previous surgery showed that the screws didn¿t miss the plate in the initial surgery.The plate malfunction result in a revision surgery where multiple screws were removed from the plate and a retrograde nail was placed.".
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Additional Manufacturer Narrative
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Although it cannot be determined at this time which of the reported screws pulled through the plate, a list of the devices used is noted below: catalog 661755, lot ah6442, qty (b)(4).Catalog 662330, lot aj1041, qty (b)(4).Catalog 662350, lot unknown, qty (b)(4).Catalog 662350, lot aj7134, qty (b)(4).Catalog 662375, lot ak1914, qty (b)(4).Catalog 662380, lot aj2418, qty (b)(4).Catalog 662385, lot ak1002, qty (b)(4).The device will not be returned.When additional information becomes available, it will be provided in a supplemental report.
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Additional Manufacturer Narrative
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Correction - please refer to h6 results code.The reported event could be confirmed, since the reported screw migration is visible on the received x-rays as described in the event description.The device was not returned for evaluation, therefore no further investigation in relation to the device is possible.A review of the device history was not possible because the lot number was not communicated.No corrective actions are required at this time.A review of the labeling did not indicate any abnormalities.Indications of material, manufacturing, or design related problems were unable to be identified as the lot number was not communicated.The complaint and the received x-rays were reviewed by medical affairs and lifecyle management with following conclusion: there was no x-ray provided which shows the complete construct in one view.On one x-ray (pangea plate set 3) are four migrated locking screws in the shaft of the femur visible.The most distal and the most proximal screw are backed out while the two screws between the backed out screws were pulled through the plate.All the affected screws in the shaft area have about the same length of around 50mm.But only two screws in this length range were returned for evaluation, the other screws are either much shorter (30mm) or longer (75mm).This means two of the affected screws, including the initially reported catalog # 662346 and as well the affected plate is missing.During the evaluation of the x-rays, it appeared that two of the displaced screws were too small and therefore may not have been held in place in the universal holes of the plate.This impression is particularly evident in the ap view (pangea plate set 5), where it appears that the screws have different diameters, and also in the lateral view (pangea plate set 4), where it appears that the head diameters of the screws are too small in comparison to the plate holes.Ultimately, without images of the entire construct, information about the patient's activities, and having all affected devices back for evaluation, it is not possible to determine the final cause of the reported event.If the device is returned or if any additional information is provided, the investigation will be reassessed.
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Event or Problem Description
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As reported: "a pangea distal femur plate was placed on (b)(6) 2025 there was a revision case done on (b)(6) 2025 where it showed multiple 5.0 locking screws going through the plate hole.Lateral x-ray from the previous surgery showed that the screws didn¿t miss the plate in the initial surgery.The plate malfunction result in a revision surgery where multiple screws were removed from the plate and a retrograde nail was placed.".
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Search Alerts/Recalls
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